Perspectives of key interest groups regarding supervised Consumption sites (SCS) and novel virtual harm reduction services / overdose response hotlines and applications: a qualitative Canadian study

Background Supervised consumption sites (SCS) and overdose prevention sites (OPS) have been implemented across Canada to mitigate harms associated with illicit substance use. Despite their successes, they still contend with challenges that limit their accessibility and uptake. Overdose response hotlines and apps are novel virtual technologies reminiscent of informal “spotting” methods that may address some of the limitations. Here, we strove to qualitatively examine the factors that may encourage or deter utilization of these virtual services and SCS. Methods A total of 52 participants across Canada were recruited using convenience and snowball sampling methods. These included people with lived and living experience of substance use, family members of people with lived experience, healthcare providers, community harm reduction workers, and virtual harm reduction operators. Semi-structured telephone interviews were conducted and inductive thematic analysis was performed to identify the themes pertaining to SCS and virtual harm reduction. Results Participants viewed overdose response hotline and apps as an opportunity to consume substances without being hindered by logistical barriers (e.g., wait times), fear of law enforcement, invasion of privacy, and more. They also noted that these virtual services provided more flexibility for clients who opt for routes of consumption that are not supported by SCS, such as smoking. Overall, SCS was perceived to be better than virtual services at facilitating social connection, providing additional resources/referrals, as well as prompt response to overdose. Conclusion In sum, participants viewed SCS and virtual services as filling different needs and gaps. This study adds to a growing body of literature which informs how virtual harm reduction services can serve as useful adjunct to more standard harm reduction methods.


Introduction
Community-led harm reduction and addiction supports have scaled up across Canada [1,2] to address the overdose crisis that has seen more than 40 000 opioid toxicity deaths between 2016 and 2023 [3].One of these efforts include supervised consumption sites (SCS), which are federally sanctioned facilities that offer safer spaces for people to consume pre-obtained drugs in the presence of trained staff [4].Today, there are 39 sites operating across Canada with an estimated number of 2700 visits each day [4].In recent years, provinces have also developed their own urgent public health sites or overdose prevention sites (OPS), which are designed to provide temporary support to local communities that require more adequate access to harm reduction supplies and services [5,6].However, SCS and OPS face numerous challenges to its implementation and operation [7,8] despite the growing body of evidence demonstrating their effectiveness and ability to reduce harms associated with substance use [9,10].Furthermore, solitary substance use continues to pose challenges in curbing overdose mortality rates [11,12], with recent data from Health Canada revealing that 78% of acute toxicity events still occur in private residences for those who are not experiencing homelessness [13].
Spotting is an informal overdose spotting technique in which individuals can consume substances under the virtual supervision of a trusted individual (e.g., a friend, or family member) [14,15].It ensures autonomous and confidential substance use without being subjected to stigma or adherence to rigid organizational policies [14,15].Born out of these grassroots efforts, formalized virtual harm reduction services such as overdose response hotlines and apps have emerged to prevent fatal overdoses, especially for those who prefer to use substances alone and/or do not have immediate access to a SCS [16][17][18][19].These services are alternatively known as Mobile Overdose Response Services (MORS) [20].Certain services like the National Overdose Response Service (NORS) [21,22] and BRAVE app [23] in Canada, as well as Never Use Alone in the United States, connect peers to an operator who can initiate a personally tailored and preplanned emergency response (e.g., calling a friend/family member or emergency medical services) when an overdose is suspected [17].In addition, British Columbia and Alberta have implemented their own timer-based mobile apps, called the LifeGuard [24] and the Digital Overdose Response Service (DORS) [25], respectively.These services activate an emergency response when the individual becomes unresponsive and is unable to shut off or renew the timer; however, they do not refer clients to a live operator.Figure 1 illustrates how some of these services function.To date, the authors are not aware of studies that have qualitatively compared these novel virtual services to more standard harm reduction strategies, such as SCS.This study aims to identify some of the strengths as well as the gaps in the current provision of virtual and inperson services to inform the development of these programs in the future.

Participants
The selected key interest groups who participated in the study consisted of: people with lived or living experience of substance use, family member of people with lived experience, healthcare providers, community harm reduction workers, and virtual harm reduction operators.Both convenience and snowball sampling were employed to recruit participants using existing networks known to the research team and one overdose response hotline service and an overdose response app services operations team.The study was open to any individuals residing in Canada who were 18 years of age or older, able to communicate effectively in English, and able to provide informed verbal consent.

Semi-structured interviews
A semi-structured interview guide was constructed by virtual harm reduction operators, people with lived and living experience of substance use, and the research team.Fifty-two telephone interviews were conducted between November 2021 and April 2022 by two evaluators (SJ and LA) from ThreeHive (a third-party research organization) with master's level training in qualitative methods.Each interview ranged from 20 to 60 min in length, and all participants were provided with a brief information package about the various virtual harm reduction services prior to the interviews.TapeACall and a third-party transcription service was used to record and transcribe the interviews, respectively.Honorariums of $50.00 CAD were only granted to people who use substances.All information provided by participants was kept confidential and stored on a secure server.No participant was excluded during or after the completion of interviews.

Coding and analysis
The major themes that pertained to the perceptions of key interest groups toward virtual services and SCS were identified using grounded theory and inductive thematic analysis [26,27].The two evaluators who conducted the interviews coded the transcripts using Dedoose software.The first three transcripts were examined together and then analyzed independently afterwards.Any discrepancies that arose during this process was resolved with the principal investigator (MG).Once the initial coding was complete, the two evaluators reviewed a representative sample of coded quotations for each theme with the consulting project manager (KM).Interviews were conducted until thematic saturation was reached across all key interest groups.Data triangulation and theme checking were performed by consulting people with lived experience, overdose response hotline and app service operators, researchers, and interested government officials.
The results were reported using the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.This study complies with Tri-Council Policy Statement for Ethical Conduct for Research Involving Humans (TCPS 2) and received approval from University of Calgary Conjoint Health Research Ethics Board (REB21-1655).

Results
Out of the total 52 individuals interviewed, 25 identified as individuals with lived experience of substance use, 5 as family members of people with lived experience, 10 as healthcare providers, 6 as community harm reduction workers, and 6 as virtual harm reduction operators.Forty-five interviewees resided in an urban area and the remaining 7 were from a rural community.Further details regarding the area of residence are shown in Table 1.The demographic information of people who use substances and the family members is available in Table 2.The interviews elucidated the following main themes regarding the perceptions of key interest groups towards hotline/ app-based and in-person services.

Limited hours of operation and wait times
Participants described limited hours of operation and long wait times (potentially increasing the risk of "dopesickness" or unwanted withdrawal) as deterrents to seeking SCS during times of substance use.Furthermore, those residing in rural/remote areas expressed frustrations towards difficulty in accessing SCS which are often centralized in urban downtown areas.Given these factors, participants viewed virtual spotting as a convenient alternative for keeping individuals safe during times of necessary solitary use.

Support for different routes of substance use
Although participants acknowledged that many SCS permit injection, nasal insufflation, and oral routes of substance use, they often did not allow the use of inhalants or smoking of the products.Some participants emphasized how virtual services can support clients regardless of their routes of consumption.

Privacy concerns
The fear of being seen at a SCS was a recurring theme among people who use substances, highlighting the prevailing issue of stigma around illicit substance use.Despite efforts to make SCS more welcoming, some participants noted that they can be "pretty intimidating to be around" (Healthcare provider) especially if the client is not familiar with the setting.Based on this finding, virtual harm reduction services may be more appropriate for clients who may prioritize anonymity and privacy.

Criminalization and altercation with law enforcement
People who use substances also cited fears surrounding the risk of arrest if they encountered law enforcement on the way to a SCS.In addition, participants highlighted how overdose response hotlines and apps could be particularly beneficial in places where the political atmosphere is not supportive of such facilities.Hence, these services were perceived as a reasonable alternative to support individuals regardless of where they are located geographically, especially in heavily policed jurisdictions and provinces where possession of illicit drugs is still criminalized.
" Relationships with the staff at SCS were seen as assisting clients meet their healthcare needs in a supportive, trauma-informed environment, and to "heal with whatever pain they're dealing with and why they're using [substances] in the first place" (Person with lived experience).The constant engagement between clients and service providers was thought to be beneficial to the overall, sustained well-being and health of people who use substances by regaining their trust in the public health care system.One virtual harm reduction operator, however, noted how some clients much preferred the hotline than the SCS.
" [Clients] said they feel more closely bonded to the people -the operators on the line.In the physical supervised consumption sites, they're often just being observed and there's less interaction with staff there.So, they're finding that there is more interaction with the operators on the NORS lines."(Virtual harm reduction operator).
Theme 3 Access to additional harm reduction and social services.
One unique benefit of SCS noted by the respondents was that they provided access to clinical services that were not always available through virtual services.For instance, SCS can be used to pick up medication and receive basic health assessments and first aid (e.g., wound care) by healthcare professionals in-person.
"I think just that social aspect is the biggest thing.And because a lot of people are accessing healthcare services at consumptions sites so maybe they're getting wound care or they're picking up their other medication, like a lot of folks that I know that attend supervised consumptions sites may get their you know daily HIV medications there." (Healthcare provider) Participants further indicated that SCS can directly provide clients with harm reduction supplies (e.g., sterile needles, pipes, filters and other paraphernalia).Additionally, while SCS could educate clients on safer substance use, participants indicated that virtual services could at best explain how to do so over the phone.Some participants also thought that SCS may also be able to provide clients with a safer supply of opioids to help mitigate the contaminated drug supply and offer additional services, including social services and a warm place for clients to shelter -both of which it was felt virtual services could not match.

Theme 4 Perceived overdose response times between SCS and virtual harm reduction services.
Many participants regarded SCS as more adept and reliable at responding to overdoses, since they are equipped with harm reduction workers and healthcare providers who can provide prompt medical assistance.However, it was deemed that virtual services are preferable to no overdose monitoring at all.
"I would say a disadvantage is, response time is much slower.compared to … brick-and-mortar SCS, but obviously, you're comparing it to none, then any response time obviously is better with a virtual one than none at all" (Person with lived experience).

Discussion
This study represents one of the first qualitative examinations of the strengths and gaps in the provision of SCS and virtual harm reduction through the lens of various key interest groups in Canada.It expands on previous studies that have examined the phenomenon of spotting and the barriers to accessing harm reduction services for people who use substances [7,14,17,28].
Our study corroborates previous works that have cited similar operational and logistical barriers to using SCS [8], which may compel people to consume substances alone [29].For instance, limited operating hours of SCS often do not cater towards people who use substances and their drug use routines [30,31], and this was consistent with the findings of our study.Crowding is another issue faced by physical facilities [31,32].The Trailer, a SCS in Ottawa has been seeing more than double the number of clients it was designed to accommodate [32].A retrospective analysis of call logs from National Overdose Response Service found that more than half of the callers could not access SCS/OPS due to reasons such as: no physical availability of SCS/OPS at the user's location, local facility being unable to support a specific route of substance consumption, and the time of substance use being outside of SCS/OPS operating hours [7].The current study has detailed how hotline and app-based overdose response services may be able to fill some of these gaps by providing 24/7 support especially when SCS is not a feasible option [33,34].
Inhalation and smoking substances are becoming more common and preferred route of consumption over injection [35,36].This creates a challenge as only a small proportion of SCS in Canada offer inhalation support due to occupational safety hazards [37,38].With the increasing prevalence of crystal methamphetamine inhalation, this gap must be addressed by carefully considering its feasibility and acceptability [39].That being said, overdose response hotlines and app services can still support individuals regardless of their preferred routes of administration at no risk to the service personnel.
Interview responses especially from people with lived experience captured concerns regarding privacy as one of the barriers to seeking in-person harm reduction services.This is a well-warranted concern given that substance use disorder is still a heavily stigmatized health status in North America, and many report not wanting to be seen by someone they know while using [30].There were also concerns around policing from respondents who resided in jurisdictions where illicit substance use was criminalized.It has been well documented in the literature that people who use substances are reluctant to call or seek emergency medical services due to legal consequences such as arrest or losing child custody despite Good Samaritan Laws [40,41].Although virtual services may still contend with issues surrounding privacy [42], findings from our study suggest that virtual services are perceived to be more reassuring than physical sites.
Finding a sense of community and building therapeutic relationships was considered a unique and valuable aspect of SCS.SCS have been previously shown to be a means to break down these barriers and reshape the perceptions of peers towards health and social services [43].While automated services like DORS and LifeGuard may be more limited in this regard, it has increasingly become a norm for peer-operated hotline services (e.g., NORS) to also facilitate social connection by providing mental health and peer support [44][45][46][47][48]. Despite this, there is still a utility for timer-based automated services for those who wish to have added privacy or have difficulty speaking about their substance use [44].
Respondents also highlighted how SCS provided necessary services that were lacking or unfeasible through virtual modalities.For instance, some sites are embedded in already existing health centers that not only provide immediate harm reduction support but also primary medical care and on-site opioid agonist treatment [43].In addition, services such as wound care, clinical support, and social services are offered in a more robust fashion at physical sites, though some services are known to provide few referral services [49].Despite this, innovative models for sterile supply distribution could be considered by overdose response hotlines and app services.Past work has suggested that mail-out kits of naloxone, needles, filters, as well as disposal containers are ways in which harm reduction services can be provisioned without a need for physical location [50].
While virtual services require activation of emergency services in the event of a suspected overdose, staff at a SCS can respond immediately due to always being physically present.Concerns regarding response times of virtual services (especially in rural communities) have been expressed by healthcare professionals and virtual harm reduction workers in previous studies [17,49].The time required to respond to overdose can very much impact the overall outcome of opioid-induced respiratory depression, with a proportional increased risk of hypoxic brain injury or even death with delays in overdose response [51].Indeed, there is growing evidence that demonstrate the effectiveness of these virtual technologies in preventing and averting drug-induced overdose deaths [16,20].The authors believe that using overdose response hotlines and app would be safer than using alone and research is ongoing to assess its safety.Virtual harm reduction providers and operators should ensure that clients are adequately informed about the limitations of these services in terms of overdose response.
Given the increasingly toxic supply of opioids driving the overdose crisis [52], virtual services may be a muchneeded service to equitably serve a large proportion of peers who do not have access to immediate spotting or other overdose prevention services [19,42,53].As mentioned previously, the scalability of virtual services compared to SCS especially amidst political or community opposition makes a strong case for these service as a reasonable adjunctive option.For example, the availability of safe injection facilities and other harm reduction services in countries like United States varies greatly by jurisdiction [54,55], and overdose response hotlines such as SafeSpot and Never Use Alone provide invaluable safeguard for people who use substances [56,57].While the data regarding the effectiveness and safety of these services requires continuous monitoring and examination, preliminary evidence indicates that virtual services could still be used to support solitary use of substances, prevent overdose, and foster a sense of community.

Strengths and limitations
One strength of this study is having a relatively large sample size of individuals recruited across Canada and representing the perspectives of various key collaborators.The convenience and snowball sampling strategies used may have limited the diversity of the participants, especially those with less knowledge of virtual services.Much of our findings were also focused on hotline versions of virtual harm reduction services as opposed to automated services and wearable sensors/buttons, due to only a minority of peers having experience with them.In addition, all participants were required to have access to a mobile device or telephone and communicate effectively in English, which may have biased our sample to anglophone populations and excluded some groups, notably recent immigrants and refugees.While our study explored the potential differences between the SCS and virtual services, uptake preferences and safety were not measured quantitatively.Lastly, an examination of differences in formal virtual "spotting" methods (e.g., overdose response hotline and apps), and informal "spotting" was not examined and would be worth exploring in future studies.

Conclusions
The findings of this preliminary study have important implications for understanding how virtual overdose response services and SCS can complement each other and understand where and in what context one service may be more applicable, acceptable, and useful than the other.These findings will further inform implementation and improvement of these services going forward.

Fig. 1 A
Fig. 1 A step-by-step illustration of how a client may use peer-operated hotline and automated timer-based services

Table 2
Demographic information of peopled with lived experience and family members